Non-Suicidal Self-Injury

Jessica Shaffer, MSW,LISW-SCassie Oliver, MSW, LISW-S

What is Non-Suicidal Self-Injury

• Numerous definitions of the term non-suicidal self-injury (NSSI) have been reported in the literature. Therefore, it has been difficult for researchers to agree on how to classify the term. Two leading researchers have attempted to define NSSI, which has come to be accepted by the majority of those in the field. Nock and Favazza (2009) describe NSSI as “the direct, deliberate destruction of one’s own body tissue in the absence of suicidal intent” (p. 9).

Common forms of Non-Suicidal Self-Injury

Cutting

Scratching (to the point bleeding occurs or marks remain on the skin)

Burning

Punching

Pinching

Carving words

Biting (to the point bleeding occurs)

What do you know about people who self-injure?

T

True of False1. Only a few very sick people self-injure.2. Teens who hurt themselves are trying to commit suicide, but they don’t

have the nerve.3. There are many ways that people self-injure.4. People who self-injure are crazy and should be put in hospitals.5. Teens who self-injure are just trying to get attention from their parents.6. Self-inflicted wounds are a way of being accepted at school.7. Only teens who have other serious psychological problems will harm

themselves. 8. If your wounds are superficial, your self injury may be just a phase.9. Girls and boys typically self-injure in different ways.(Shapiro (p.9)

How Common is NSSI

•Some studies suggest that about 13 to 25% of adolescents and young adults surveyed in schools have some history of self injury (Rodham &Hawton, 2009).

•Studies also indicate that many of these individuals self injury once or twice, then stop.

Who self- injures?There is no single “self-injurer” profile.

Why Self-injure?

Current research suggests that self-injury shares many of the risk factors of other negative coping mechanisms: history of trauma and/or abuse (particularly sexual or emotional abuse), poor family communication, low family warmth, and/or perceived isolation (Yates, 2004).

• Most often, NSSI is used to regulate intense negative emotion.• To calm down quickly• To evoke emotion when they feel numb or dissociated• As a means of self control, punishment, or distraction.• To increase energy or improve mood• To solicit attention or be part of a group

Self injury according to (Self injury: a practical guide) can often seem to be part of an adolescent expression

of angst and alienation; among teens there may be considerable social reinforcement for the behavior.

Knowing the self injury facts can help you better understand the underlying origins of this behavior and the techniques of self harm.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV-TR) lists self injurious behavior as a symptom of borderline personality disorder, but recent research indicates that it also occurs with other mental health disorders,including:Eating disordersDepressionAnxiety disordersSubstance abuseConduct and oppositional disordersThe phenomenon has become more visible in society in recent years. 

DSM 5

Nonsuicidal Self-InjuryProposed CriteriaA. I the last year, the individual has 5 or more days, engaged in intentional self-

inflicted damage to the surface of his or her body of a sort likely to induce bleeding, bruising, or pain (e.g., cutting, burning, stabbing, hitting, excessive rubbing), with the exception that the injury will lead to only minor or moderate physical harm (i.e., there is no suicidal intent). Note the absence of suicidal intent has either been stated by the individual or can be inferred by the individual’s repeated engagement in a behavior that he individual knows, or has learned, is not likely to result in death.

B. The individual engages in the self-injurious behavior with one or more of the following expectations.

DSM 5

1. To obtain relief from a negative feeling or cognitive state.2. To resolve an interpersonal difficulty.3. To induce a positive feeling state.Note: The desired relief or response is experienced during or shortly after the self-injury, and the individual may display patterns of behavior suggesting a dependence on repeatedly engaging in it.

C. The intentional self-injury is associated with at least one of the following:4. Interpersonal difficulties or negative feelings or thoughts, such as depression, anxiety,

tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act.

5. Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to control.

6. To induce a positive feeling state.

DSM 5C. The intentional self-injury is associated with at least one of the following:1. Interpersonal difficulties or negative feelings or thoughts, such as depression,

anxiety, tension, anger, generalized distress, or self-criticism, ocucurring in the period immediately prior to the self-injurious act.

2. Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to control.

3. Thinking about self-injury that occurs frequently, even when it is not acted upon.

D. The behavior is not social sanctioned (e.g., body piercing, tattooing, part of a religious or cultural ritual) and is not restricted to picking a scab or nail biting.E. The behavior or its consequences cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning.

DSM 5F. The behavior does not occur exclusively during psychotic episodes, delirium, substance intoxication or substance withdrawal. In individuals with a neurodevelopmental disorder, the behavior is not part of a pattern of repetitive stereotypies. The behavior is not better explained by another mental disorder or medical condition (e.g., psychotic disorder, autism spectrum disorder, intellectual disability, Lesch-Nyhan syndrome, stereotypic movement disorder with self-injury trichotillomanit, excoriation disorder.)

Risk and Prognostic FactorsTwo theories of psychopathology- based on functional behavioral analyses- have been proposed: In the first, based on learning theory, either positive or negative reinforcement sustains the behavior. Positive reinforcement might result from punishing oneself in a way that the individual feels is deserved, with the behavior inducing a pleasant relaxed state or generating attention and help from a significant other, or as an expression of anger. Negative reinforcement results from affect regulation and the reduction of unpleasant emotions or avoiding distressing thoughts, including thinking about suicide. In the second theory, nonsuicidal self-injury is thought to be a form of self-punishment, in which self-punitive actions are engaged in to make up for acts that caused distress or harm to others.

Differentiating NSSI from Suicide

All to often NSSI is labeled as “suicidal.” This can result in unnecessary psychiatric hospitalizations and other inappropriate interventions.

Recognizing/Identifying common signs and symptoms for self-injury

• Preference for wearing concealing clothing at all times (i.e. long sleeves in hot weather)

• Avoidance of situations where certain types of clothing are required• Unusually frequent complaints of injury

Common body sites for self-injury

• Arms• Hands• Wrists• Thighs • Stomach

Social Media Impacts on Self Harm Behavior

• YouTube• Google• Pinterest• Playlists

Differentiating Suicide Attempts from Self-Injurious Behavior

Assessment Focus Suicide Attempt Self-injury

What was the expressed and unexpressed intent of the act?

To escape pain/ terminate consciousness

Relief from unpleasant affect (tension, anger, emptiness, deadness)

What was the level of physical damage and potential lethality?

Serious physical damage, lethal means of self-harm

Little physical damage, nonlethal means used

Is there a chronic, repetitive pattern of self-injurious acts?

Rarely a chronic repetition, some overdose repeatedly

Frequently a chronic, high-rate pattern

Have multiple methods of self-injury been used over time?

Usually one method Usually more than one method over time

What is the level of psychological pain?

Unendurable, persistent Uncomfortable, intermittent

Is there constriction of cognition?

Extreme constriction, suicide as the only way out, tunnel vision, seeking a final solution

Little or no constriction, choices available, seeking a temporary solution

Are there feelings of hopelessness and helplessness?

Hopelessness and helplessness are central

Periods of optimism and some sense of control

Differentiating Suicide Attempts from Self-Injurious BehaviorAssessment focus Suicide attempt Self injury

Was there a decrease in discomfort following the act?

No immediate improvement, treatment required for improvement

Rapid improvement, rapid return to usual cognition and affect, successful “alteration of consciousness”

Restriction of means Important, often life-saving Impractical, often inadvertently provocative

What is the core problem? Depression, rage abut inescapable, unendurable pain

Body alienation, exceptionally poor body image in clinical populations

The intent of the suicidal person is likely to stop the psychological pain/ to make the pain

go away permanently.

The intent of the self-injurer is to modify the pain. The self-injuring person wants to reduce distress, in order to live another

day.

• The Centers for Disease control and Prevention (CDC, 2010) identify death by suicide as occurring via six basic methods; use of a firearm (50.7%); hanging (23.1%); pill or poison ingestion (18.8%); jumping from a height (1.6%); use of a sharp instrument (1.7%); and death involving motor vehicles, such as cars, trains, or buses (1.1%).

• Thus is to say that 98.3% of individuals who die by suicide in the United Stated use methods other than cutting. Those who die by cutting use very specific and uncommon methods: 1) severing the carotid artery or jugular vein in the neck, 2) piercing the heard, or 3) performing a massive incision to the abdomen (CDC, 2010).

• The most common form of self-injury, cutting the arms or legs is not listed as a method that results in death; nor are other forms of common self injury.

Frequency of Behavior

• The large majority of people who attempt suicide do not do so recurrently or frequently.

• The most common pattern is that people attempt suicide once or twice when they are in a particularly stressful period (Nock & Kessler, 2006).

• There are those in the minority- who attempt suicide recurrently over extended periods of time. These are usually persons who have a serious and persistent mental illness (e.g., major depression, bipolar disorder, borderline personality disorder).

Frequency of Behavior

• The majority of self-injuring persons perform the behavior frequently.

• A commonly reported frequency by self-injuring clients is 20-100 times over a multiple year period.

• It is very common for self-injury to be a high rate behavior

NSSI Vs. Suicidal Behavior

• While research has shown that self-injury may be distinct from suicide, it has also been shown to be an important risk factor for suicide attempts.

• In beginning treatment with anyone that self-injuries, it is important to simultaneously assess for suicidal thoughts plans and past behavior.

• Evidence suggests that those with repetitive history of self-injury are at a great risk or suicide attempts (Nock et al.; 2006.)

NSSI Vs. Suicidal BehaviorWarning Signs

• Self-injury is no longer working

• Ideation

• Substance abuse

• Purposelessness

• Anxiety

• Trapped

• Helplessness

• Withdrawal

• Anger

• Recklessness

• Mood Changes

Treatment for Non-suicidal Self-injury

• Serotonin Level Dysfunction Currently a number of studies have linked diminished serotonin levels with impulsive aggression and self injury.The use of selective serotonin reuptake inhibitors is designed to assist the body in using existing serotonin levels most efficiently.

Treatment for Non-suicidal Self-injury

•Dispassionate Demeanor

Intense reactions may inadvertently re-inforce the behavior

A nurturing, overly solicitous response may be immensely gratifying for people who have ben neglected, ignored or abused.

Condemnation and recoil may be paradoxically rewarding, especially for adolescents who take some gratification in provoking strong reactions in adults.

Treatment for Non-suicidal Self-injury

• Use a calm, dispassionate demeanor in responding to the behavior. • Be respectfully curious• Nonjudgmental compassion

In General in responding to non-suicidal self-injury it is most helpful to1. Avoid the use of suicide terminology2. Use clients own descriptive language3. Challenge language that is minimizing4. Remain aware of the risks of providing secondary reinforcement5. Use a low key, dispassionate demeanor6. Convey respectful curiosity7. Be nonjudgmental and compassionate

Self Protection ContractBaseline date (frequency of self-injury):

Goal (reduced frequency of self-injury):

Skills to be used in place of self-injury:1.2.3.4.

Reward for reaching goal:

Commitment:Signature:___________________Witness:____________________Date:______________________For the time period of_________ to_________

Treatment for Non-suicidal Self-injury

• Dialectical Behavior Therapy (DBT)• Cognitive Treatment• Replacement Skills Training• Family Therapy• Psychopharmacological Treatment

• NHS video

Dialectical Behavior Therapy

• Dialectical behavior therapy (DBT) is a specific type of cognitive-behavioral psychotherapy developed in the late 1980s by psychologist Marsha M. Linehan to help better treat borderline personality disorder. Since its development, it has also been used for the treatment of other kinds of mental health disorders.

Cognitive Treatment

• Cognitive behavioral therapy (CBT) is a form of treatment that focuses on examining the relationships between thoughts, feelings and behaviors.

Replacement Skills Training

• 1. Negative replacement behaviors• 2. Mindful breathing skills• 3. Visualization techniques• 4. Physical exercise• 5. Writing• 6. Artistic expression• 7. Playing or listening to music• 8. Communicating with others• 9. Diversion techniques

Replacement Behaviors

• Negative replacement behaviors

1. Marking one’s body with a red-colored marker rather than cutting or burning ( symbolic representation of wounding, but without tissue damage)

2. Applying BenGay or other topical stimulants to a previously injured body area (tactile sensation, but without tissue damage)

3. Snapping a rubber band on the area of an arm or leg that is usually cut or burned (tactile sensation and a stinging discomfort, but without tissue damage)

4. Briefly applying ice or portable cool packs to body areas usually assaulted (physical stimulation and discomfort, but without tissue damage)

5. Holding a frozen orange in the hand (same as applying ice/cool packs)6. Applying a temporary tattoo to a portion of the body and scratching it off with a

finger nail (tactile stimulation of the area usually harmed, but without tissue damage)

Negative Replacement Behaviors

• Gently stroking a previously assaulted body area with a soft cosmetics brush or other soft implement (soothing that which was previously harmed)

• Drawing a picture depicting the self-injury of a body area (visual cues representing self-injury, but without tissue damage)

• Writing about the act of self-injuring in great detail, from start to finish of an episode, without implementing the scenario (beginning of a transition to verbal mastery, while distancing the client from the immediacy of self-harm)

• Dictating a self-injury sequence into a recording device (verbal mastery and distancing)

[Note these strategies include tactile, visual and auditory options.]

Negative Replacement Behaviors

• This is a controversial set of skills. Some researchers have argued against using what they call “negative replacement behaviors” stating that the activities are too fraught with associations to self-injury. Arguing that replacement behaviors are too likely to trigger relapse. They recommend avoiding or even forbidding clients from using negative replacement behaviors.

• Other researchers have found that negative replacement behaviors can be productive in at least the short term. Stating that some clients use negative replacement behaviors early in treatment because they represent familiar territory and serve an important role in transition.